Healing And Repair

Healing And Repair

Stages of Repair And Recovery After An Injury

Most of us have experienced an occasional injury: The sprained ankle, a whiplash, the knee or shoulder injury, the shin bump on the corner of the coffee table, a sun burn, or a paper cut (ouch).  Following the injury you begin to experience pain. Then inflammation begins. Pain occurs after your brain has sensed that there was an injury, that there was some level of tissue damage and something needs to be done. Your body responds to tissue damage with inflammation followed by tissue repair and remodeling. Eventually, you heal.  But are you really done with the healing process?

Stage 1 - The Inflammatory Stage

0 to 5 days. Gradual reduction of inflammation occurs over three to six weeks. White blood cells move into injured tissues sealing off the sight of injury and remove injured tissues.


  • Use Pain as your guide, avoid it.
  • Non-steroidal anti-inflammatories generally become ineffective after two weeks.
  • No more than two days rest.
  • M.I.C.E.: Motion, Ice, Compression, Elevation. Easy, gentile and pain-free movement in the middle range of motion.

Stage 2 - The Proliferation Stage

5 days to 6 weeks. Scar producing cells (fibroblasts, tenocytes) move into the injured area resulting in collagen and fibrous tissue formation. Initially, this scar tissue is very weak – 15% the strength of normal tissue.


  • Use pain as your guide: movements just into stiffness and gentle pain. Should abate upon release of movement.
  • Movements in mid range. Generally you can achieve full range by 3-4 weeks.
  • Continuous Low Level Heat Therapy (CLHT) 2-4 hours a day to increase blood flow and improve healing rate. (Thermocare)
  • If pain persists, the inflammatory process has been retriggered and healing will be delayed. Return to M.I.C.E.

Stage 3 - The Remodeling Stage

About 6 weeks to 1 year or more based on the type of tissue injured and severity of original injury. Healing tissue is resized and reshaped and vascularization is reduced. Initially, consolidation occurs: tissue becomes more fibrous and fibers become aligned with in direction of stress. Finally, the tissue matures: fibrous tissue changes to scar tissue, and eventually contraction of scar tissue occurs, and tensile strength increases.

Despite remodeling, the properties of healed tendon tissue never match those of intact tendon. Furthermore, often tendons can heal with adhesion formation which often affects their mobility and function. This type of healing prevails in torn rotator cuffs.


  • Goal: increase stress to scar tissue. Re-educate the new scar tissue of existing tissue properties and increase tissue strength to handle normal function. This is accomplished mainly through eccentric exercises.
  • Pain is less of a guide, especially in more chronic conditions. Here the guide is "No Worse."
  • Achieve end range of motion intermittently, not prolonged.
  • Load, transition to unloading, and then unload joints and muscles.
  • Changes of structural elements are accomplished with 10-12 reps, every 2-3 hours for 16-24 weeks.

Guidelines For The Use Of Ice And Heat

Guidelines For The Use Of Ice

Ice reduces pain by slowing nerve activity. This effect can persist up to 30 minutes. Trauma to the surrounding tissue combined with inflammation can result in secondary injury. Ice slows this process and shortens the healing process and aids. Also, reflex activity and motor function are impaired following ice treatment increasing susceptibility to injury for up to 30 minutes after treatment.

  • First, determine that the injury is minor and requires no further medical treatment. Otherwise, seek medical help immediately: The sooner you get medical help when necessary, the quicker your recovery.   
  • Use ice during the initial days after an injury to reduce inflammation.  
  • Use a towel between you and the ice.
  • Alternate 10 minutes on and 10 minutes off for several applications.

Guidelines For The Use Of Heat

  • Use heat after the initial inflammatory stage. Used too early heat will increase the inflamatory response.
  • Use a very wrung-out towel between you and the heat source.
  • Continuous Low Level Heat Therapy (CLHT) 2-4 hours a day can also be extremely helpful and is good for problems that are worse at night or in the morning: use patches at night.

Guidelines For Heat Versus Ice After The Initial Inflammatory Stage:

  • ICE: If pain is constant and not relieved by position.
  • ICE: If the end of the day is worse than the beginning.
  • ICE for the day: If the morning of the next day is worse than the day before. 
  • Otherwise: HEAT.

Factors That Prolong Healing Time

  • Lack of protection or not reducing the swelling in the first few days.
  • Continued inflammation. This could be the direct result of mechanical injury or by thought patterns inappropriate for the condition.
  • Lack of early mobilization. Gentle, painless, mid range movement in the first week results in stronger repair.
  • Smoking, caffeine, diabetes, heart disease.
  • Physical behavior: too much or too little activity based on the stage of healing.
  • Inappropriate behaviors in dealing with pain and its consequences – fear avoidance, anxiety, catastrophising, depression, etc.

Extended Reading

Explore this link to learn more about healing, and the use of ice and heat.